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A 72-year-old woman who presented with a unilateral oculomotor nerve palsy was shown to have a very rare condition: multiple dural arteriovenous fistulae (DAVF) involving the cavernous and sphenoparietal sinuses. The sphenoparietal DAVF was cured completely by transarterial embolisation. Symptomatic relief was accomplished by this procedure. The cavernous sinus DAVF progressed to acquire cortical venous drainage, and was obliterated completely by transvenous embolisation.

Spontaneous extradural hematomas are rare and may be caused by pericranial infections, bleeding tendencies, or vascular abnormalities of the dura mater. The authors describe a case of spontaneous bilateral extradural hematomas assumed to be caused by a bleeding tendency with hypofibrinogenemia. A brief review of the literature is reported.

A 72-year-old female with intradiploic haemangioma associated with epidural haematoma is reported. MRI finding of the lesion is described. The cause of the epidural haematoma is speculated due to fragile vessels attached directly to dura mater through the pores of the inner table of the diploë.

The angiographic changes in neck remnants of ruptured cerebral aneurysms treated with Guglielmi detachable coils (GDCs) were evaluated in the acute stage to analyze the important radiological and clinical factors. The clinical and radiological data of 37 patients with a residual neck of a ruptured cerebral aneurysm treated with GDC were reviewed. The angiographic changes on follow-up angiography were classified into three groups: recanalization of the neck remnant, progressive thrombosis, and unchanged. The effects of the clinical and angiographic findings, such as patient age, follow-up period, type of aneurysm (terminal type or side wall type), dome diameter, neck size, dome/neck ratio, obliteration rate, and volume embolization ratio were investigated. Recanalization of the neck remnant was observed in 18 of 37 cases, progressive thrombosis in nine, and unchanged in 10. The type of aneurysm, dome diameter, neck size, and volume embolization ratio were correlated with changes in the neck remnant. The aneurysm dome diameter and type of aneurysm were independent predictive factors for the recanalization of neck remnants on follow-up angiography. Dome diameter of less than 4.5 mm and volume embolization ratio of more than 31% in side wall aneurysms were likely to lead to progressive thrombosis

Medullary streaks are linear structures on MRI crossing the white matter of the brain, which can be observed in aging brain or patients with moyamoya disease. 1 The increases in medullary streak diameter that accompany advancing age coincide with, and are thought to represent, age-related enlargement of fluid-filled perivascular spaces that have been shown by histology to accompany senile brain atrophy. 2 On the other hand, medullary streaks in moyamoya disease are speculatively considered to represent compensatorily dilated medullary vessels rather than the perivascular spaces. 1 In this report, we demonstrate contrast enhancement of the medullary streaks in two patients with severe chronic cerebral ischemia (advanced moyamoya disease and progeria syndrome), which supports this hypothesis. We also propose that the medullary streaks and the ivy sign (leptomeningeal enhancement on postcontrast T1-weighted images or hyperintensity on fluidattenuated inversion recovery [FLAIR] images) 3 in ischemic conditions have the same pathogenesis: compensatorily dilated medullary and pial vessels.Case reports. Case 1. A 9-year-old girl with transient alternating monoparesis several times a year for 6 years was referred to our hospital. On admission, her neurologic examination was unremarkable except for bilateral extensor plantar responses. FLAIR images (figure, A) revealed prominent medullary streaks. Postcontrast spin-echo T1-weighted images (figure, B) demonstrated enhancement of the medullary streaks and the ivy sign. Conventional angiography revealed bilateral stage 4 moyamoya disease. Subsequent studies after successful encephalo-duroarterio-synangiosis showed disappearance of medullary streaks on FLAIR images (figure, C).Case 2. An 8-year-old girl with the diagnosis of progeria syndrome (Hutchinson-Gilford syndrome) presented with transient paresthesias in her right extremities. Her neurologic examination on admission was unremarkable except for bilateral increased deep tendon reflexes and extensor plantar responses.Diffusion-weighted imaging revealed acute infarctions in the left frontal watershed region and in the right deep white matter. MR angiography revealed occlusion or severe stenosis of both internal carotid arteries, probably due to atherosclerosis associated with progeria syndrome. T2-weighted images 2 months after the onset of symptoms revealed medullary streaks, in addition to infarctions in the white matter. Postcontrast T1-weighted images (figure, D) demonstrated enhancement of the medullary streaks and the ivy sign.Discussion. Our findings support the concept that the imaging finding of medullary streaks may represent either dilated perivascular spaces or dilated medullary vessels. Perivascular spaces typically do not enhance after contrast administration unless the blood-brain barrier has been disrupted, as in patients with lymphoma or neurosarcoidosis due to infiltration of lymphoma cells or granulomatous leptomeningitis into the perivascular spaces. 4 However, such infiltration was unlikely in the pre...

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